FORMAT ASUHAN KEPERAWATAN tesis mahasiswa

FORMAT ASUHAN KEPERAWATAN
Bangsal/ruangan

: .......................

Tanggal Masuk : .......................

Nomor kamar

: .......................

Tanggal Pengkajian

: .......................

I. Pengkajian
A. Identitas
1. Klien
Nama Klien

: ...................

Umur

: .......... tahun

Jenis kelamin

:

Laki-laki

Status marital

:

Belum menikah

Agama

: .....................................

Suku/Bangsa

: .....................................

Bahasa yang digunakan

:

Perempuan
Menikah

Indonesia
Daerah : ................
Asing : ................

Pendidikan

: .....................................

Pekerjaan

: .....................................

Alamat Rumah

: .................................................................................

2. Penanggung Jawab
Nama
Alamat Rumah
Hubungan dengan klien

: ...................
: .................................................................................
: ...................

B. Data Medik
Diagnosa Medis
 Saat masuk

: ...........................................................
 Saat pengkajian
: ...........................................................
C. Alasan masuk rumah sakit
..................................................................................................................
Keluhan utama saat pengkajian : .......................................................................

D.

Riwayat kesehatan saat ini : (PQRST)

Paliatif/penyebab....................................................................................................
Qualitas /..................................................................................................................
Region......................................................................................................................
Skala.........................................................................................................................
Timing.......................................................................................................................
E. Riwayat kesehatan masa lalu :
II. Penyakit yang pernah diderita : .....................................................................
III. Pernah dirawat

:

ya

tidak

bila ya, kapan dan dimana dirawat : .................................................................
IV. Pernah dioperasi

:

ya

tidak

bila ya, waktu operasi:
: ...........................................................................
tempat operasi
: ...........................................................................
Jenis tindakan operasi : ...........................................................................

V. Alergi terhadap obat, makan, dll :
bila ya, sebutkan
VI. Imunisasi

ya

: .................................................................................
: .................................................................................

VII. Kebiasaan merokok, alkohol dan obat-obatan :
bila ya, sebutkan

tidak

ya

tidak

: .................................................................................

A. Riwayat kesehatan keluarga:
1.
Susunan anggota keluarga
Genogram : ( 3 generasi)

2.

Penyakit yang pernah diderita anggota keluarga : .............................................

3.

Kesehatan orang tua (jika yang sakit anak)

: .............................................

4.

Saudara kandung

: .............................................

5.

Hubungan keluarga dengan klien

: .............................................
6.

Anggota keluarga lain yang tinggal serumah

7.

Faktor risiko penyakit tertentu dalam keluarga, seperti :
Kanker

: .............................................

Hipertensi

Penyakit jantung Epilepsi

Diabetes melitus
TBC

Penyakit lainnya, sebutkan ................................................................
B. Kebiasaan sehari-hari
1. Nutrisi - Cairan
a. Keadaan sejak sakit

:



Napsu makan

: .............................................



Frekuensi makan

: .............................................



Jumlah makan yang masuk
Kurang satu porsi
Satu porsi penuh
Lebih dari satu porsi



Diet

: .............................................



Ketaatan terhadap diet tertentu

: .............................................



Mual/enek

: .............................................



Muntah

: .............................................



Nyeri ulu hati

: .............................................



Jumlah minum/24 jam

: .............................................



Jenis minum

: .............................................



Keluhan makan dan minum

: .............................................

2. Eliminasi
a. Keadaan sejak sakit

:



Frekuensi BAB/24 jam

: .............................................



Waktu BAB

: .............................................



Warna feses

: .............................................



Konsistensi



Bentuk feses

: .............................................



Penggunaan pencahar

: .............................................

: .............................................



Keluhan BAB

: .............................................



Melena

: .............................................



Konstipasi



Frekuensi BAK/24 jam

: .............................................



Warna urine

: .............................................



Volume urine

: .............................................



Bau urine

: .............................................



Masalah pengontrolan buang air besar

: .............................................



Kolostomi

: .............................................



Sering menahan buang air kecil

: .............................................



Keluhan saat buang air kecil

: .............................................

:

Disuria
Buang kecil tidak lancar
Harus mengejan saat buang air kecil
Urine menetes
Urine tidak bisa keluar sama sekali (retensi urine)
pengeluaran Urine tidak bisa dikontrol (inkontinensia)
Berkemih tidak terasa
Malam banyak berkemih (nokturia)
Hematuri



Penggunaan kateter



Peningkatan perspirasi/keringat

: .............................................
: .............................................

3. Aktivitas - latihan
a. Keadaan sejak sakit


:

Aktivitas perawatan diri
 Makan

:

 Mandi

:

 Berpakaian

:

 Kerapian

:

 Buang air besar

:

 Buang air kecil

:

 Mobilisasi ditempat tidur

:

 Ambulasi

:

Keterangan :
0 : mandiri
1 : bantuan dengan alat
2 : bantuan orang
3 : bantuan orang dan alat
4 : bantuan penuh

 Kesimpulan :.......................................................................................


Rekreasi selama dirawat

: .............................................

4. Tidur - istirahat
a. Keadaan sejak sakit


:

Tidur siang

:

ya

bila ya, berapa jam

: ............ jam

tidak



Tidur malam

: ............ jam





Kebiasaan sebelum tidur
Keluhan tidur
Ekspresi wajah mengantuk

: .............................................
: .............................................
Negatif
Positif



Banyak menguap

:

Negatif

Positif



Palpebrae inferior warna gelap

:

Negatif

Positif

:

C. Data psikologis
1. Persepsi tentang penyakitnya
2. Suasana hati/air muka
3. Daya konsentrasi

: .............................................
: .............................................
: .............................................

4. Koping

: .............................................

5. Konsep diri

: .............................................

6. Stressor

: .............................................

D. Data sosial
1. Tempat tinggal

: .............................................

2. Hubungan dengan keluarga/kerabat

: .............................................

3. Hubungan dengan klien lain

: .............................................

4. Hubungan dengan perawat

: .............................................

5. Adat istiadat yang dianut

: .............................................

E. Data spritual
Agama yang dianut

: .............................................

Apakah agama sangat penting bagi anda

: .............................................

Jika ya, dalam hal apa

: .............................................

Kegiatan keagamaan selama dirawat

: .............................................

Apakah selalu berdoa untuk kesembuhan

: .............................................

F. Pemeriksaan Fisik
1. Keadaan sakit : Klien tampak sakit ringan/ sedang/ berat/ tidak tampak sakit
Alasan

: ...............................................................................................
...............................................................................................

2. Tanda-tanda vital
a. Kesadaran
1) Kualitatif :

Kompos mentis (alert)

Lethargi

Somnolent (obtunded) Stuporous
Semicoma

Coma

2) Kuantitatif :
 Glasgow Coma Scale

:

Respon motorik (M)

: .......

Respon bicara

: .......

(V)

Respon membuka mata (E)
 Jumlah

: ..........

 Kesimpulan

: ...................................

: .......

b. Tekanan darah : ............. mmHg
MAP

: ............. mmHg

Kesimpulan

:...................................................................................

c. Nadi : frekuensi ......... kali/menit, volume................, ritme .................
d. Suhu : ...... oC
e. Pernapasan

Oral

Axila

Rectal

: frekuensi ........ kali/menit
Irama :

teratur
Kusmaul

jenis

:

dada

tidak teratur
Cheyness-stokes
perut

3. Antropometri
a. Lingkar lengan atas

: ............ cm

b. Lipat kulit triceps

: ............ cm

c. Tinggi badan

: ............ cm

d. Berat badan

: ............ cm

e. IMT (Indeks Massa Tubuh : .................. kg/m2
Kesimpulan

: ...................................................

4. Kepala
a. Bentuk kepala

:

Simetris

tidak simetris

Cephalo hematome

: .............................................................................

Ukuran

: .............................................................................

Fontanel

: .............................................................................

b. Warna rambut

:

c. Keadaan rambut

:

Hitam

Coklat

Pirang

Perak

Rontok

Pecah-pecah

Tumbuh subur
d. Kulit kepala

:

Kotor dan bau

Lesi

Ketombe

Bersih

e. Bengkak/benjolan

: .............................................................................

f.

Nyeri/pusing

: .............................................................................

g. Keluhan lain

: .............................................................................

5. Mata/Penglihatan
a. Ketajaman penglihatan : ...................................................................
b. Alis

: ...................................................................

c. Bulu mata :
Warna

: ...................................................................

Kondisi/distribusi

: ...................................................................

Posisi

: ...................................................................

Peradangan

: ...................................................................

d. Simetris
e. Sclera :

:
Putih dan jernih

ya

tidak

Kuning/ikterik
kebiruan
f.

Pupil


Bentuk

:

bulat

tidak bulat



Kesamaan ukuran

:

isocor

anisocor



Warna

:

gelap

keruh & tidak berwarna



Reaksi terhadap cahaya

:

miosis

midriasis



Refleks pupil (test N.III)

:

sama besar, bulat dan bereaksi terhadap cahaya
mengecil
melebar
g. Palpebra :
edema
peradangan
Ptosis
lagopthalmus
baik/normal

h. Konjungtiva

: .............................................................................

i.

Bola mata

: .............................................................................

j.

Gerakan bola mata

: .............................................................................

k. Lapang pandang
l.

Cornea & iris

: .............................................................................

:

Abrasi

: .............................................................................

Kejernihan

: .............................................................................

Refleks kornea : .............................................................................
m. Peradangan

: .............................................................................

n. TIO

: .............................................................................

o. Keluhan penglihatan : .............................................................................
p. Alat bantu penglihatan: .............................................................................

kaca mata
kontak lensal
tidak menggunakan alat bantu
6. Hidung/Penciuman
a. Struktur luar :


Ukuran

: ..............................................................................



Bentuk

: ..............................................................................



Kesimetrisan

: ..............................................................................

b. Struktur dalam :


Warna

:

merah muda

kemerahan keabu-abuan

c. Fungsi penciuman (test N.I)

: ...................................................................

d. Perdarahan

: ...................................................................

e. Lain-lain

: ...................................................................

7. Telinga/pendengaran
a. Struktur luar :
Warna

: ...................................................................

Lesi

: ...................................................................

Cerumen

: ...................................................................

Membran timpani

: ...................................................................

b. Fungsi pendengaran

:

Test Rinne

: ...................................................................

Test Weber

: ...................................................................

Test Swabach

: ...................................................................

c. Nyeri

: ...................................................................

d. Alat bantu

: ...................................................................

e. Keseimbangan
f.

Lain-lain

: ...................................................................
: ...................................................................

8. Mulut/Pengecapan
a. Bibir
Warna

: ...................................................................

Kesimetrisan

: ...................................................................

Kelembaban

: ...................................................................

Kondisi:

Pecah-pecah, berdarah
Biru/sianosis
Pucat
Bengkak

b. Mukosa mulut
Warna

: ...................................................................

Kelembaban

: ...................................................................

Lesi

: ...................................................................

c. Gigi

:

Kebersihan

:

bersih

tidak bersih

Caries

:

ada

tidak ada

Kelengkapan

:

lengkap tidak lengkap

d. Gigi palsu

: ..................................................................

e. Keadaan gusi

: ..................................................................

f.

: ...................................................................

Keadaan lidah

g. Peradangan

: ...................................................................

h. Fungsi mengunyah

: ...................................................................

i.

Fungsi mengecap

: ...................................................................

j.

Fungsi bicara

: ...................................................................

k. Bau mulut

: ...................................................................

l.

Gag refleks

: ...................................................................

m. Refleks menelan

: ...................................................................

n. Lain-lain

: ...................................................................

9. Leher
a. Kelenjar getah bening

: ...................................................................

b. Kelenjar thyroid

: ...................................................................

c. Kelenjar sub mandibulalis

: ...................................................................

d. JVP

: ...................................................................

e. Kaku kuduk

: ...................................................................

f.

: ...................................................................

Sulit menelan

g. Lain-lain

: ...................................................................

10. Dada
a. Bentuk :

Simetris

tidak simetris

Dada membusung (pectus carunatum)
Dada berbentuk corong (pectus excavatum)
Dada berbentuk tong (barrel chest)

b. Kwalitas napas ;

cepat
lambat
dalam
dangkal

c. Suara napas :
Vesiculer
Broncho vesiculer
Bronchial/tracheal
Ronchi
Wheezing
d. Perkusi dada :
Pekak/datar
Redup/dullness
Resonan
Tympani
e. Ekspansi paru

: ...................................................................

f.

: ...................................................................

Batuk

g. Sputum
h. Nyeri dada

: ...................................................................
: ...................................................................

i.

Tactile fremitus

: ...................................................................

j.

Pergerakan rongga dada : ...................................................................

k. Penggunaan otot nafas tambahan

: ......................................................

l.

Lain-lain

: ...................................................................

11. Kardiovaskuler/SIrkulasi
a. Batas jantung

: ...................................................................

b. Heart rate

: ...................................................................

c. Bunyi jantung I

: ...................................................................

d. Bunyi jantung II

: ...................................................................

e. Bunyi jantung tambahan

: ...................................................................

f.

: ...................................................................

Nyeri dada

g. Palpitasi
h. Edema

: ...................................................................
: ...................................................................

i.

Cyanosis

: ...................................................................

j.

Jari-jari tabuh

: ...................................................................

k. Lain-lain

: ...................................................................

12. Abdomen/pencernaan
a. Keadaan kulit

: ...................................................................

b. Bising usus

: ...................................................................

c. hepar

: ...................................................................

d. limfa

: ...................................................................

e. Nyeri tekan

: ...................................................................

f.

: ...................................................................

Benjolan-benjolan

g. Gembung

: ...................................................................

h. Ascites

: ...................................................................

i.

: ...................................................................

Lain-lain

13. Muskulo skeletal
a. Kekuatan otot ekstremitas atas: ...................................................................
b. Kekuatan otot ekstremitas bawah:.................................................................
c. Tonus otot

: ...................................................................

d. Kaku sendi

: ...................................................................

e. atropi

: ...................................................................

f.

: ...................................................................

ROM

g. Trauma/lesi

: ...................................................................

h. Nyeri

: ...................................................................

i.

Refleks

j.

Kecacatan/deformitas

: ...................................................................
: ...................................................................

k. Lain-lain

: ...................................................................

14. Genitourinaria
Laki-laki :
a. Penis/skrotum

: ...................................................................

b. Testis

: ...................................................................

c. Fungsi seksual

: ...................................................................

d. Pertumbuhan rambut
e. Pembengkakan
f.

: ...................................................................
: ...................................................................

Nyeri daerah perineal

: ...................................................................

g. Kebersihan genitalia

: ...................................................................

h. Kebersihan anus

: ...................................................................

i.

: ...................................................................

Lain-lain

Perempuan :
a. Menstruasi

: ...................................................................

b. Kehamilan

: ...................................................................

c. Konstrasepsi yang digunakan : ...................................................................
d. Pemeriksaan usap vagina

: ...................................................................

e. Pertumbuhan rambut

: ...................................................................

j.

Fungsi seksual

: ...................................................................

k. Nyeri daerah perineal

: ...................................................................

f.

: ...................................................................

Kebersihan genitalia

g. Kebersihan anus

: ...................................................................

h. Lain-lain

: ...................................................................

15. Keadaan neurologi
a. Tingkat kesadaran

: ...................................................................

b. Koordinasi

: ...................................................................

c. Memori/daya ingat

: ...................................................................

d. Orientasi (tempat,orang,waktu) : ...............................................................
e. Tremor

: ...................................................................

f.

: ...................................................................

Gangguan motorik/lumpuh

g. Kejang

: ...................................................................

h. Fungsi nervus I s/d XII :
N.I (Olfactorius)

: ...................................................................

N.II (Optikus)

: ...................................................................

N.III (Oculomotorius)

: ...................................................................

N.IV (Trochlearis)

: ...................................................................

N.VI (Abducn)

: ...................................................................

N.V (Trigeminus)

: ...................................................................

N.VII (Facialis)

: ...................................................................

N.VIII (Cochlea vestibularis)

: ...................................................................

N.IX (Glosopharingeus) : ...................................................................
N.X (Vagus)

: ...................................................................

N.XI (Accesoris)

: ...................................................................

N.XII (Hypoglosus)

: ...................................................................

i.

Refleks tendon

j.

Refleks permukaan

: ...................................................................
: ...................................................................

k. Refleks patologik

: ...................................................................

i.

: ...................................................................

Lain-lain

16. Sensasi terhadap rangsangan
a. Rasa nyeri

: ...................................................................

b. Rasa suhu

: ...................................................................

c. Rasa raba

: ...................................................................

17. Integumen/Kulit
a. Warna
flushing (kemerahan)/alamiah/sawo matang/putih
cyanosis
biru kemerahan
Joundice/ikterus
Pallor (pucat)
b. Tekstur
halus/licin
lunak
fleksibel
keriput
c. Turgor
d. Kelembaban

: ...................................................................
: ...................................................................

e. Suhu kulit :
Hangat
Dingin
Normal/alamiah
f.

Lesi
macula, lokasi ……………………….
Papula, lokasi ………………………
Nodula, lokasi ……………………….
Tumor, lokasi ……………………….
Vesicula, lokasi ……………………….
pustula, lokasi ……………………….
Ulkus, lokasi ……………………….

g. Kelainan warna

: ...................................................................

h. Pucat

: ...................................................................

i.

: ...................................................................

Pigmentasi
hipo pigmentasi
hiperpigmentasi
normal/alamiah

j.

Edema
+1
+2
+3
+4

k. Keadaan kuku :

l.

panjang

pendek

Kebersihan kuku

: ...................................................................

Lain-lain

: ...................................................................

18. Catatan tambahan
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
G. Pemeriksaan diagnostik :
1. Laboratorium :
a. Darah

: ..............................................................................................
..............................................................................................
..............................................................................................
..............................................................................................

b. Feses

: ..............................................................................................
..............................................................................................
..............................................................................................

c. Urin

: ..............................................................................................
..............................................................................................
..............................................................................................

d. Sputum : ..............................................................................................
..............................................................................................
e. Lain-lain

: ..............................................................................................
..............................................................................................

2. Radiologi

: ..................................................................................
..................................................................................
..................................................................................

3. EKG

: ..................................................................................
..................................................................................

4. EEG

: ..................................................................................
..................................................................................

5. USG

: ..................................................................................
..................................................................................

6. Pemeriksaan lainnya

: ..................................................................................
..................................................................................
..................................................................................

H. Program terapi :
1. Obat-obatan
.................................................

.................................................

.................................................

.................................................

.................................................

.................................................

.................................................

.................................................

2. Fisioterapi

: ...........................................................................

Tanda tangan mahasiswa yang mengkaji
Jambi,

(
NPM.

2016

)

ANALISA DATA
NAMA PASIEN

: ...............

UMUR

: ...............
DATA

KEMUNGKINAN PENYEBAB

MASALAH

NCP
NO

DIAGNOSA
KEPERAWATAN

INTERVENSI

RASIONAL

CATATAN PERKEMBANGAN
NAMA PASIEN

UMUR
NO TANGGAL
MUNCUL

: ...............

: ...............
DIAGNOSA
KEPERAWATAN

CATATAN
PERKEMBANGAN

TANDA
TANGAN

CATATAN KEPERAWATAN
NAMA PASIEN

: ...............

UMUR

: ...............

TANGGAL
JAM

DIAGNOSA
KEPERAWATAN

CATATAN KEPERAWATAN

TANDA
TANGAN

CATATAN PERKEMBANGAN
NAMA PASIEN

: ...............

UMUR

: ...............

NO

TANGGAL
JAM

DIAGNOSA
KEPERAWATA
N

PERKEMBANGAN
SOAP

TANDA
TANGAN